Basic Information
| Provider Information | |||||||||
| NPI: | 1477502250 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ST CLAIR | ||||||||
| FirstName: | JESSE | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7068 | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 237070068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7576863516 | ||||||||
| FaxNumber: | 7576860230 | ||||||||
| Practice Location | |||||||||
| Address1: | 1708 OLD DONATION PARKWAY | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234543064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573955300 | ||||||||
| FaxNumber: | 7572139341 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2006 | ||||||||
| LastUpdateDate: | 12/01/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 0101032201 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | PAR | 01 | VA | MULTIPLAN | OTHER | PAR | 01 | VA | FIRST HEALTH COMMERCIAL/SOUTHERN HEALTH/COVENTRY | OTHER | 1477502250 | 05 | VA | MEDICAID | 259556 | 01 | VA | ANTHEM BCBS | OTHER | PAR | 01 | VA | VIRGINIA PREMIER HEALTH | OTHER | 890555R | 05 | NC | MEDICAID | PAR | 01 | VA | CIGNA | OTHER | PAR | 01 | VA | VIRGINIA HEALTH NETWORK | OTHER | -001 | 01 | VA | TRICARE/CHAMPUS | OTHER | 35080 | 01 | VA | OPTIMA/SENTARA | OTHER | PAR | 01 | VA | AETNA | OTHER | PAR | 01 | VA | USA MANAGED CARE | OTHER | 428960 | 01 | VA | UHC/MAMSI | OTHER | 10015738 | 01 | VA | SENTARA OPTIMA | OTHER | 006055486 | 05 | VA | MEDICAID | 0555R | 01 | NC | BCBS | OTHER | 248020 | 01 | VA | ANTHEM | OTHER | PAR | 01 | VA | CORVEL/CORCARE | OTHER |